Breaking bad news about transitions to dying: a qualitative exploration of the role of the District Nurse

Breaking bad news: Comparing the perception of the role, barriers and experiences of neonatal intensive care and well-baby nursery nurses

BACKGROUND

Nurses accompany patients throughout the breaking bad news process.

AIM

The aim of the research was to compare neonatal intensive care unit (NICU) nurses and well-baby nursery (WBN) nurses on their role, barriers and experiences in breaking bad news to parents/relatives during hospitalization.

STUDY DESIGN

A cross-sectional comparative study.

RESULTS

Two medical centres in Israel were employed. A 39-item questionnaire was distributed with 140 nurses participating in the study. STROBE Checklist was used. A total of 140 nurses participated in this study. There was no significant overall difference (p ≤ .45) between NICU and WBN nurses in their perception of their role in breaking bad news. Differences were found in barriers to the role which included a lack of information, lack of time and communication issues. No differences were found in the nurses' experiences in breaking bad news. NICU and WBN nurses reported that they received no support (n = 40, 58.8%; n = 45, 64.3%, respectively). No breaking bad news specialty team existed in either unit (NICU: n = 64, 91.4%; n = 60, 87.0%).

CONCLUSIONS

Nurses in the WBN and NICU are involved in breaking bad news. The role of the nurse has not been fully acknowledged making it difficult to perform. Nurses' experiences in breaking bad news were varied. Nurses facing challenges should be provided guidance and support. This needs to be implemented.

RELEVANCE TO CLINICAL PRACTICE

The role played by nurses in breaking bad news has not been fully acknowledged making it difficult to perform. Nurses need to receive formal training and support in order to improve this practice.

A global exploration of palliative community care literature: An integrative review

AIM

This review sought to discover how community nurses globally provide palliative care, with specific focus on how they manage the personal and professional stressors associated with caring for dying clients in the home.

DESIGN

An integrative review methodology was used to gain insight into how community palliative care is delivered worldwide.

BACKGROUND

The provision of home palliative care by community nurses gives clients the ability to spend their final days in familiar surroundings. Research has focussed on the provision of palliative care in the inpatient setting, with little known about the community setting.

METHODS

Data were collected through a literature search, then a critical analysis approach was used to evaluate the strengths of palliative care literature by analysing recurrent themes to stimulate further research on the topic.

DATA SOURCES

The following databases were used to conduct the literature search: CINAHL, Medline, Pubmed, Scopus, Ovid.

RESULTS

The results highlighted the importance of building a skilled palliative community nursing workforce and the need to offer specialised palliative care training to nurses, particularly around difficult conversations and service coordination.

CONCLUSION

The literature identified the challenges implicit within the community nursing role in delivering palliative care, but it did not identify the factors that enhance the nurses' ability to manage the stressors associated with this role. The input of nurses must be sought to understand the development of resilience.

IMPLICATIONS FOR THE PROFESSION

Community palliative care nursing requires time spent with clients and family members who are suffering, therefore predisposing nurses to stress. Effort must be made to provide palliative care nurses with support to enhance professional resilience.

A Literature Review of Nurses Challenges and Barriers in Assisting Patients and Families Facing Breaking Bad News

Objectives

Breaking bad news (BBN) is a challenging task for healthcare professionals, including nurses. The manner in which bad news is delivered can have a significant impact on patients and their families, either positive or negative. Understanding the roles, methods, obstacles, and challenges that nurses face in the process of delivering bad news is crucial for improving the quality of the delivery process.

Material and Methods

This narrative review synthesises related studies. The search was conducted through PubMed, Scopus, ScienceDirect and Sage, with no restriction on publication year. The main keywords were 'nurse's challenge', 'nurse's barrier', 'bad news', 'breaking bad news', and 'communicating bad news.' A total of 12 articles were selected from 1075 articles.

Results

Nurses play a key role in BBN before, during and after the process. Their activities include preparing patients to receive bad news, supporting patients and families when doctors deliver bad news and clarifying information obtained by patients and families regarding the prognosis of their illness. Nurses should possess skills such as building interpersonal relationships, therapeutic communication and providing emotional care for patients and their families. The main challenges and barriers for nurses in implementing BBN are due to a lack of skills and unpreparedness for patient and family reactions. After BBN, the most reported roles of nurses were supporting patients and families and helping them understand the information received from doctors. It is essential for nurses to have the necessary skills and preparedness to effectively deliver bad news to patients and their families.

Conclusion

Nurses play a crucial role in delivering bad news to patients and their families. They should be equipped with the necessary skills to effectively communicate with patients and their families during this difficult time. Further training for nurses in therapeutic communication, emotional care for patients and their families, and building interpersonal relationships could help to improve the quality of the delivery process.

The contribution of generalist community nursing to palliative care: a retrospective case note review

Background: There is a paucity of evidence regarding the contribution of generalist community nursing to palliative care. Aim: The aim of this study was to identity the proportion of patients referred to a generalist community nursing service who meet the criteria for palliative care need and explore key aspects of their management. Methods: A retrospective case note review of people known to a generalist community nursing service was undertaken to identify people with palliative care needs. Results: Of the 1284 people enrolled in the community nursing service, 21.1% (n=271) were identified as having palliative care needs, of which most (82.7%; n=224) had a non-cancer illness. However, palliative care need was largely unrecognised in the referrals to community nursing and there was little evidence of a palliative approach being integrated into nursing care. Conclusions: Nursing has a significant role in the provision of generalist palliative care in the community. However, research is needed to identify the barriers community nurses experience identifying needs and providing palliative care. A focus on education and support in implementing screening tools, which may assist community nurses in recognising needs and delivering palliative in the generalist setting, is urgently needed.

Factors Associated with Japanese Nurses' Support on End-of-life Decision-making: A Cross-sectional Study

PURPOSE

This study aimed to clarify the factors associated with Japanese nurses' end-of-life decision-making support.

DESIGN

Cross-sectional study.

METHODS

An online survey was conducted among 278 nurses.

FINDINGS

Significantly associated factors included visiting nursing, nursing experience duration, female sex, workshop participation, and time spent on end-of-life care.

CONCLUSION

Visiting nursing was the most significant factor associated with nurses' end-of-lifedecision-making support.

CLINICAL EVIDENCE

Consideration should be given to the curriculum in basic nursing education related to visiting nursing. It shouldinclude end-of-life care as well as resources for end-of-life decision-making to increase the number of patients who die in their preferred setting.

Critical Care Nurses’ Attitudes, Roles, and Barriers Regarding Breaking Bad News

This study examines critical care nurses’ attitudes, roles, experience, education, and barriers regarding breaking the bad news. A descriptive, cross-sectional design was used in this study. A convenience sample of 210 critical care nurses completed the study. Most of the critical care nurses contributed to breaking bad news and they were involved in different roles in this process and they had a positive attitude regarding breaking bad news. In this study, (75.2%) of the participants reported that they did not receive any specific training regarding breaking bad news. In addition, nurses face various barriers when breaking bad news. Critical care nurses’ involvement in breaking bad news should be encouraged. Most barriers to BBN were negatively associated with nurses’ roles, attitudes, and experiences during BBN. Administrators should promote the involvement of critical care nurses in breaking bad news and strengthen them through addressing the challenges they face in the process of BBN.

Clinicians' accounts of communication with patients in end-of-life care contexts: A systematic review

OBJECTIVE

Communication between patients and end-of-life care providers requires sensitivity given the context and complexity involved. This systematic review uses a narrative approach to synthesise clinicians' understandings of communication in end-of-life care.

METHODS

A systematic, narrative synthesis approach was adopted given the heterogeneity across the 83 included studies. The review was registered prospectively on PROSPERO (ID: CRD42019125155). Medline was searched for all articles catalogued with the MeSH terms "palliative care," "terminal care" or "end-of-life care," and "communication". Articles were assessed for quality using a modified JQI-QARI tool.

RESULTS

The findings highlight the centrality and complexity of communication in end-of-life care. The challenges identified by clinicians in relation to such communication include the development of skills necessary, complexity of interpersonal interactions, and ways in which organisational factors impact upon communication. Clinicians are also aware of the need to develop strategies for interdisciplinary teams to improve communication.

CONCLUSION

Training needs for effective communication in end-of-life contexts are not currently being met.

PRACTICE IMPLICATIONS

Clinicians need more training to address the lack of skills to overcome interactional difficulties. Attention is also needed to address issues in the organisational contexts in which such communication occurs.

Aims, actions and advance care planning by district nurses providing palliative care: an ethnographic observational study

District nurses are core providers of palliative care, yet little is known about the way that they provide care to people at home. This study aimed to investigate the role and practice of the district nurse in palliative care provision. This was an ethnographic study, with non-participant observation of district nurse-palliative care patient encounters, and post-observation interviews. District nurse teams from three geographical areas in northwest England participated. Data were analysed iteratively, facilitated by the use of NVivo, using techniques of constant comparison. Some 17 encounters were observed, with 23 post-observation interviews (11 with district nurses, 12 with patients/carers). Core themes were 'planning for the future' and 'caring in the moment'. District nurses described how they provided and planned future care, but observations showed that this care focused on physical symptom management. District nurses engaged in friendly relationship building, which allows detailed management of symptomatology, but with little evidence of advance care planning.

Conspiracy of Silence in Palliative Care: A Concept Analysis

BACKGROUND AND AIM

With chronic diseases on the rise, there is a growing demand for palliative care. The global landscape of the integration of palliative care into health-care systems is incipient, which leads to a lack of social awareness of this reality and consequently, to communication failures, particularly a conspiracy of silence. The aim of this study was to analyze the concept of conspiracy of silence in palliative care.

MATERIALS AND METHODS

Walker and Avant method of concept analysis was used. Review and synthesis of literature supported the analysis process. Forty-seven articles were analyzed.

RESULTS

Results showed that the conspiracy of silence in palliative care is a communication failure, typical of limited life expectancy prognosis, and involves patients, their families, and health-care teams. Lack of autonomy, overburden, family malfunctioning and coping, and health-care dehumanization are consequences of the conspiracy of silence in palliative care.

CONCLUSIONS

The present study had found that scales to measure this concept as well as interventions that consider important factors in the communication process in palliative care identified in this analysis are needed.

Striving for a balance between leading and following the patient and family - nurses' strategies to facilitate the transition from life-prolonging care to palliative care: an interview study

Background

The transition from life-prolonging to palliative care (PC) can be challenging often characterized by psychical, physiological, social and existential changes. Knowledge of how to support the patient and family in this specific care phase is lacking, and this area needs to be further explored. The aim of this study was to investigate strategies that registered nurses (RNs) use to ease the transition from life-prolonging care to PC for patients with incurable disease.

Methods

The study has a descriptive design. Fourteen RNs working in a specialized PC unit were interviewed. The data were analysed using content analysis.

Results

The RNs’ strategies can be described under the categories “Getting to know the patient and creating a relationship”, “Providing support”, “Adapting to individuals’ needs” and “Enabling conversations”.

Conclusion

The findings show that the RNs in this population used strategies that not only took time but also required knowledge about the transition process and required the ability to identify and meet patients’ and families’ unique needs. Patients’ difficult and exposed situation needs to be addressed through a structured follow-up after informing about the change from life-prolonging care to PC. RNs have a unique role of supporting both the patient and the family in the transition from life-prolonging care to PC for patients with incurable disease.

Analysing the impact of a case management model on the specialised palliative care multi-professional team

PURPOSE

Palliative care (PC) involves many health care providers leading to a high complexity of structures that requires efficient coordination as provided by case management (CM). Our study aimed to evaluate the effects of CM newly implemented in a specialised palliative care unit by evaluating team members' tasks and time resources before (T0) and after implementation (T1). It was hypothesised that team members would be able to spend less time on organisational and administrative tasks and more time on patient care.

METHODS

A prospective pre-post study design was used. Time distribution of different tasks at T0 and T1 was compared between three different professional groups: physicians, nursing staff and social work. To document their tasks and time required, a documentation form with several items for each profession was developed. Data was analysed using t tests for independent samples.

RESULTS

After Bonferroni correction, a significant pre-post difference was found for the time spent on "discharge interview and discharge" as rated by the physicians (p < .001) with less time spent on this activity after CM implementation. The nursing staff had significantly more time for "conversations with patients" (p < .001) after CM implementation. Moreover, they spent significantly less time on "patient-related requests/advice by telephone" (p < .001) and "discussions with relatives/participation in family discussions" at post-assessment (p < .001). The social worker had significantly more time for "patient advice and support services" (p = .013) after CM implementation.

CONCLUSIONS

Integrating CM can be time efficient and ensures team members to spend more time on their core tasks in patient care.

Nurses' Perceptions of Diagnosis and Prognosis-Related Communication: An Integrative Review

BACKGROUND

Disclosure of diagnostic and prognostic information has become the standard in the United States and increasingly around the world. Disclosure is generally identified as the responsibility of the physician. However, nurses are active participants in the process both intentionally and inadvertently. If not included in initial discussions regarding diagnosis and prognosis, the nurse may find it challenging to openly support the patient and family.

OBJECTIVE

The aim of this study is to synthesize published literature regarding nurses' perceptions and experiences with diagnosis and prognosis-related communication.

METHODS

The Whittemore and Knafl method guided the integrative review process. Electronic databases including Cumulative Index to Nursing and Allied Health Literature, Health Sciences in ProQuest, PubMed, and Web of Science were used to review the literature from 2000 to 2015. Constant comparison methods were used to analyze the data and develop themes.

RESULTS

Thirty articles met all of the inclusion criteria and were included in this review. Several themes emerged from the data, including the nurse's role in the process of diagnosis and prognosis-related communication, barriers and difficulties related to communication, and positive and negative outcomes.

CONCLUSIONS

Nurses play an integral role in the process of diagnostic and prognostic disclosure. Further exploration of both physician and patient perceptions of the nurse's role are needed. Interprofessional training regarding diagnosis and prognosis-related communication is essential to promote collaboration and better empower nurses in this process.

IMPLICATIONS FOR PRACTICE

Nurses should aim to purposefully partner with physician colleagues to plan and participate in diagnostic and prognostic discussions. Nurses should identify opportunities to improve their knowledge, understanding, and comfort with challenging conversations.

A qualitative study of community nurses' decision-making around the anticipatory prescribing of end-of-life medications

AIMS

The aim of this study was to explore community nurses' decision-making processes around the prescribing of anticipatory medications for people who are dying.

BACKGROUND

Community nurses frequently initiate the prescribing of anticipatory medications to help control symptoms in those who are dying. However, little is known about their decision-making processes in relation to when they instigate anticipatory prescribing and their discussions with families and General Practitioners.

DESIGN

A qualitative interpretive descriptive enquiry.

METHODS

A purposive sample of 11 Community Palliative Nurses and District Nurses working in one geographical area participated. Data were collected between March and June 2016 via audio recorded semi-structured interviews and analysed inductively using Braun and Clarke's thematic analysis.

RESULTS

Three themes were identified: (1) Drugs as a safety net. Anticipatory medications give nurses a sense of control in last days of life symptom management; (2) Reading the situation. The nurse judges when to introduce conversations around anticipatory medications, balancing the need for discussion with the dying person and their family's likely response; (3) Playing the game. The nurse owns the decision to initiate anticipatory medication prescribing and carefully negotiates with the General Practitioner.

CONCLUSION

Nurses view pain control through prescribed medication as key to symptom management for dying people. Consequently, they own the role of ascertaining when to initiate discussions with families about anticipatory medicines. Nurses believe they advocate for dying person and their families' needs and lead negotiations with General Practitioners for medications to go into the home. This nurse led care alters the traditional boundaries of the General Practitioners-nurse professional relationship.

The difficulties experienced by nurses and healthcare staff involved in the process of breaking bad news

AIMS

The aim of this study was to explore the difficulties experienced by nurses and healthcare professionals when engaging in the process of breaking bad news.

BACKGROUND

The challenges faced by staff when breaking bad news have previously been researched in relation to particular settings or participants. This study involved staff from diverse settings and roles to develop broader insights into the range of difficulties experienced in clinical practice.

DESIGN

The study used a descriptive survey design involving self-reported written accounts and framework analysis.

METHODS

Data were collected using a structured questionnaire containing a free text section that asked participants to describe a difficult experience they had encountered when involved in the process of breaking bad news. Data were collected from healthcare staff from hospital, community, hospice and care home settings attending training days on breaking bad news between April 2011 and April 2014.

FINDINGS

Multiple inter-related factors presented challenges to staff engaging in activities associated with breaking bad news. Traditional subjects such as diagnostic and treatment information were described but additional topics were identified such as the impact of illness and care at the end of life. A descriptive framework was developed that summarizes the factors that contribute to creating difficult experiences for staff when breaking bad news.

CONCLUSION

The framework provides insights into the scope of the challenges faced by staff when they engage in the process of breaking bad news. This provides the foundation for developing interventions to support staff that more closely matches their experiences in clinical practice.

Approaches to continuing professional development: putting theory into practice

This article provides an overview of approaches to and models of education to assist nurses involved in the delivery of education and continuing professional development. A number of models will be summarised to look at how learning, teaching and assessment can be integrated to benefit the learner, and the benefits this may have in nursing education and continuing professional development courses. The author also considers different domains of learning: cognitive, psychomotor and affective. This article presents the case for considering the constructive alignment of educational content as one means of increasing the likelihood of it being translated into practice.

The use of protocol in breaking bad news: evidence and ethos

This article discusses health professionals use of protocol in the breaking of bad news, focusing particularly on the well-known SPIKES framework. The evidence of impact on the patient experience is examined and recommendations are made for further outcome-based research. Existing evidence suggests that the model as commonly interpreted may not fully meet the needs of patients or reflect the clinical experience of breaking bad news for some professionals and further guidance may be needed to support them in their practice. The ethos of the step-wise protocol is debated, questioning whether it helps or hinders individualised care and the formation of a genuine relationship between patient and professional. Finally, recommendations for practice are offered.

Providing end-of-life care in general practice: findings of a national GP questionnaire survey

BACKGROUND

With increasing numbers of people living with complex life-limiting multimorbidity in the community, consideration must be given to improving the organisation and delivery of high-quality palliative and end-of-life care (EOLC).

AIM

To provide insight into the experience of GPs providing EOLC in the community, particularly the facilitators and barriers to good-quality care.

DESIGN AND SETTING

A web-based national UK questionnaire survey circulated via the Royal College of General Practitioners, NHS, Marie Curie, and Macmillan networks to GPs.

METHOD

Responses were analysed using descriptive statistics and an inductive thematic analysis.

RESULTS

Responses were received from 516 GPs, who were widely distributed in terms of practice location. Of these, 97% felt that general practice plays a key role in the delivery of care to people approaching the end of life and their families. Four interdependent themes emerged from the data: continuity of care - which can be difficult to achieve because of resource concerns including time, staff numbers, increasing primary care workload, and lack of funding; patient and family factors - with challenges including early identification of palliative care needs and recognition of the end of life, opportunity for care planning discussions, and provision of support for families; medical management - including effective symptom-control and access to specialist palliative care services; and expertise and training - the need for training and professional development was recognised to enhance knowledge, skills, and attitudes towards EOLC.

CONCLUSION

The findings reveal enduring priorities for policy, commissioning, practice development, and research in future primary palliative care.

Exploring the district nurse role in facilitating individualised advance care planning

Health-care policy recognises the importance of engaging people in making decisions related to the management of their health. Advance care planning (ACP) offers a framework for decision making on end-of-life care. There are positive indicators that ACP enables health professionals to meet people's preferences. However, there are reports of insensitive attempts to engage people in end-of-life care decision making. District nurses are in the ideal position to facilitate ACP, as they have the opportunity to build relationships with the people they are caring for--an antecedent to sensitive ACP--and in recognising and fulfilling this role, they could ameliorate the risk of insensitive ACP. Distric nurse leaders also have a role to play in ensuring that organisational and environmental factors support appropriate ACP facilitation including: training, fostering a team culture that empowers district nurses to recognise and meet their ACP role, and advocating for appropriate ACP evaluation outcome measures.